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CHAPTER ONE

CHAPTER ONE . SCOPE OF THE PROBLEM . Recreational use deeply ingrained in our social life . 25% of patients seen by PC Physicians 20%-50% hosp. admits Major cause of ischemic stroke in adults Most common cause of psychosis Suicide 30x as common

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CHAPTER ONE

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  1. CHAPTER ONE SCOPE OF THE PROBLEM

  2. Recreational use deeply ingrained in our social life • 25% of patients seen by PC Physicians • 20%-50% hosp. admits • Major cause of ischemic stroke in adults • Most common cause of psychosis • Suicide 30x as common • Suicide is cause of death in 35% of IVDU and 5% of alcohol dependent

  3. Violence • 56% of all assaults are alcohol-related • More likely to engage in child abuse • Alcohol use with ½ homicides in US • 42% of women seeking tx abused • 49% women, 12% men sexually abused

  4. MVA • 40-60% in US will be involved in alcohol related accident at some point • The problem of use/abuse/addiction effects everyone

  5. Physicians Less than 1/5 physicians prepared • Fail to screen for • Seen as a “waste of time” • Resist making referrals • Lack training • Many consider the problem untreatable

  6. Other providers • Nurses get less than 2-4 hours of class work on addiction • MFTs rarely address • 74% psychologists admit no formal training on addictions • Many believe not a true disease

  7. Numbers • 35% of men, 18% of women are predicted to develop substance abuse d/o • 5-10% adults-serious alcohol problem • 1-2% serious illicit drug problem • IVDU seen as the stereotype but only account for less than 1% • There is discrepancy in the numbers

  8. Alcohol Use, abuse, addiction • Declining use since the 80s • Used by 119 million in US • 9, 12 to 16.27 million addicted • 34% of US population consumes 62% of the alcohol produced • 2:1-3:1 ratio male female • Most commonly abused substance

  9. Narcotics • Globally 10 million abuse heroin • 810,000 in US heroin (some say 1 million) • Hidden population

  10. Cocaine • Globally 15 million use, majority in North America (some say 2.5 million in US) • Only a fraction on users become addicted • 3%-20% of users become addicted • Other research concludes 1 in 6 or 1 in 12 become addicted

  11. Marijuana • Most common abused illegal drug in US • 25% US population used at least once • 9 million regular users and 3 million are thought to be addicted

  12. Hallucinogens • Non-addictive? • 10% US pop. Used once • Rare

  13. Tobacco—oh no, not that • 46 million Americans smoke • About half men and half women • The most addictive drug • 420,000 smokers die each year • 35,000-56,000 non-smokers die each year

  14. Costs • $81 billion in lost productivity • $37 billion premature death • $44 billion because of illness • 100,000 die from illness or accidents • Drug related deaths due to infant deaths, OD, suicides, homicides, MVA, diseases • All forms of recreational use ¼-1/3 deaths

  15. Other costs • Criminal activity • Social welfare programs • Medical costs, rising health care costs • Insurance rates • Law enforcement

  16. Why is the problem hard to understand? • Media boycott of info • Disinformation • Just say NO • War on Drugs spin • Discrepancies in research #s (10-30% in US addicted? 2-10%

  17. Chapter 2 Definitions • Terms abuse and addiction confused • what do we mean?

  18. Continuum • Use falls somewhere between abstinence and addicted

  19. Level 0: total abstinence • Individual abstains from all use • No immediate risk

  20. Level 1: Rare/Social Use • Experimental use • Low risk of disorder • Rare use of alcohol or drugs for recreational purposes • No social, $, interpersonal, medical or legal problems because of use • No loss of control or threat

  21. Level 2: Heavy social use/early problem drug use • Use is above the norm • Begin problems legal, social, occ…… • Risk for disorder • More numerous than those addicted • Symptoms develop • May be able to still control use • Might hide of deny • Not yet addicted

  22. Level 3: Heavy problem use/early addiction • Addicted-starting to have problems • Medical complications/ withdrawal • Preoccupation, loss of control, increased tolerance

  23. Level 4: Addicted • Demonstrates all symptoms: social, medial, legal, $, job, relationships • Denial • Physical d/o • Everyone else seems to know

  24. Definitions • Social Use: use is in a social context • Substance Abuse:use w/o medical need to do so. Drinking in excess of social standards • Drug of Choice (DOC)- (term is not used much as rare that a person only uses one substance • Addiction/dependence: poorly defined, used interchangeably

  25. Physical Dependence • Primary Disease • Multiple manifestations • Progressive and fatal • Loss of control • Preoccupation • Continued use despite consequences • Distortions in thinking • Tolerance • Withdrawal

  26. What do we know? • Mistaken assumptions • What about people who use and never become addicted, recover on own, chippers • VA research • Little is known about adolescent use • Tx programs lack data

  27. Valid DX-DSM-IV • Craving/compulsion: thoughts become fixated on use • Loss of control • Consequences: use despite these; social, legal, medical, $, job, family

  28. Chap 3: Medical Model • Why do people use? Feels good, make a decision…………

  29. Factors influence recreational use • Physical reward potential-operant conditioning • Social learning-taught how to use, recognize effects, find pleasurable • Individual Expectations for a drug evolve in childhood, media, peers, parental use • Might vow to never use • Cultural influences • Social feedback • Individual Life goals

  30. Addiction-DSM-IV • Preoccupation • Using more chemical then planned • Withdrawal • Use to avoid withdrawal • Repeated efforts to cut back or quit • Unplanned use • Avoiding social, job, activities • Continued use despite consequences • 4 or more of these signs=addiction

  31. Medical/Disease Model • Addiction is a medical d/o • Biological predisposition/vulnerability • Disease is progressive • Model not universally accepted • Tx from counselors, not doctors • Jellinek-Handout, impact on how AODU viewed, previously looked at as a moral d/o, research flawed.

  32. Twin studies 1981 • Cloninger, Bohman, Sigvardsson • 3,000 cases of individuals adopted • COAs were likely to grow up addicted even when adopted at birth to non-addicted parents • The children that grew up to be alcoholic fell into 2 groups • Three-quarters developed d/o

  33. Type I Group • Late onset • Functioning • Rarely criminal • COA’s adopted by middle class at birth had 50/50 chance of alcoholism

  34. Type II Group • Smaller group • Male • Criminal • Violent • Early onset • Strong genetic influence

  35. Biological differences Many research studies conducted that have suggested that people who are alcoholic are somehow different biologically from those who are not Metabolize alcohol differently Reaction to the effects are different Gene studies No unequivocal biochemical or biophysical difference has been identified

  36. Chapter 4 Are people predestined to become addicted? • What are the causes of addiction? Are certain people just pre-destined to become alcoholic or addict? • Lets look at the theoretical models on page 30 • No single model dominates the field like the medical model

  37. Critics of the medical/disease model • Biophysical dysfunction is an abnormal function of the body • Infection, bacteria or virus invades the host organ • Genetic disorders lead to abnormal growth or function of the body • Alcoholism is not automatically progressive like Jellinek claimed. New research indicates severe d/o in 25-30% of cases • Loss of control over alcohol use challenged by researchers-many heavy drinkers control how much they drink • Researchers have failed to identity a single alcohol gene • Behavioral scientists agree there is a genetic “loading” that increases the risk for the disorder

  38. Environmental Influences • Have been ignored • Research suggests a great impact • Strongest evidence is the ratio of male to female. In the US 5.4:1 • In reality nonfamilial alcoholism accounts for 51% of all alcohol dependent persons • There still does appear to be a genetic predisposition , but does not mean that person will become alcoholic. Should be looked at as risk

  39. Other challenges • Evidence of social, cultural, environmental influences • Dopamine receptor sites- fewer • Even if a disease the etiology and treatments are largely social • We exempt addiction from our beliefs about change, seen as an escapable pattern of behavior-gives the credit to the disease and not the person • Many view addiction as a “brain disease”-reward system

  40. What exactly are the addictive disorders? • Bad habit, internet addiction, running addiction, shopping, chocolate? • New “diseases” lets pass the buck • Are we a nation of blamers & victims • Who benefits financially? • What about ADHD and methylphenidate? • Why do we classify certain drugs as bad and others totally socially acceptable?

  41. The secret death toll • 1 out of 131 oupt. deaths are drug mistakes in US • 125,000 US deaths per yr. adverse reactions to prescribed medications • 2.21 million US injured each year do to drug mistakes by professionals • 5x the # of deaths caused by recreational drug use

  42. Overlooked fact • Unlike other diseases, A/D disorder requires the active participation of the “victim” in order to exist • The d/o does not force itself on the individual or magically appear • Consider heroin addiction

  43. O’Brien and McLellan 1996 • Offered challenges to disease model: A/D addiction is chronic disease, like adult onset diabetes or hypertension where there are behavior factors that help to shape the evolution of the d/o. • Ultimately the people retain responsibility for their behavior even if they have a disease

  44. Politics of addiction • Many counselors resist change • Tx changed very little in last 40 yrs. • Counselors lack training and often use their own history as a guide • Tx methods not clinically based • Would we admit that tx does not work? • When tx does not work who gets the blame? When it works who often gets the credit?

  45. Personality factor • Thrill seeking, rebellious, aggressive • At this point this is a clinical myth

  46. Oh what about….. • Misapplied by judges, legislators, DHS –go get treatment • Armed with diagnosis the social workers, law enforcement, lawyers have assumed power to define how the deviant behavior will be treated • War on drugs/arm of gov. enforcement • Power out of the hands of mental health and SA counselors • Flipside- sending the chronic to treatment over and over and over again-6 OWIs or 3 child removals

  47. Final common pathway (FCP) • A non theory • Not a starting point but and end point of a unique pattern of growth • No single cause • Many factors, social, psychological, coping, spiritual shortcoming, or other factors • Acknowledge genetic predisposition • Life experiences

  48. Strong support for Final common pathway • Might be found in latest neuro-biological research findings • Mesolimbic reward system- • Dopamine levels

  49. Chapter 5 Disease of the Human Spirit • To some this best describes addiction • A disconnect with a relationship with “self” and with a “higher power” is replaced with chemicals • Spirit-Latin word meaning “breath” and “divine living force within us” • Only through relationships does our life have definition. (Merton) The relationship is defined by how much of the “self” one offers to another and what flows back in return (Buber)

  50. AA’s View • Alcoholism is a disease, not of the body but of the spirit • No focus on “causes”, only on the healing process or recovery • Recapture the spiritual unity that he or she could not find in chemicals • Assume that any person whose use interferes with his or her life has an addiction problem. Either is or is not alcoholic

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